The Process of CognitiveBehavioral Therapy

The process of becoming a therapist can be daunting. Clients who are suffering with emotional and behavioral problems entrust their therapists with their deepest thoughts and feelings and perhaps share experiences with us that they have never shared with anyone else. They place hope in us that we will be able to fix what ails them. This is a great responsibility.

Given that psychotherapy is a human interaction, we must remember that our clients come into this situation with beliefs they held long before their interactions with us. Perhaps they had negative experiences with other therapists. Maybe they grew up with highly critical parents. Years of failure at school and work might have led them to believe that they can never succeed, even with great effort. We must accept our clients as they walk in the door. Whatever they bring with them becomes part of our work together.

Engaging in psychotherapy means being faced with emotions all day. Over the course of a typical day, a therapist might sit with anger, sadness, intense anxiety, or even steely silence that is hard to attach to any one emotion. We must learn how to react effectively to our clients' emotional states and how to leave work at the end of the day in a comfortable emotional place, rather than carrying the burden of our clients into our lives outside of work.

Moreover, being a therapist involves exposure to all sorts of different behaviors. Every day, we meet clients who engage in dysfunctional behaviors like smoking, drinking, binge eating, and gambling. We encounter clients who fail to engage in the behaviors that might improve their lives — for example, a depressed client who stays in bed all day rather than getting up and doing things that might help him or her feel better. We see clients who miss out on participating in their lives because of fear and avoidance. It can also be challenging to regularly meet people who hold views we might personally disagree with (e.g., supporting a political view we find repugnant) or who engage in behaviors that we find morally wrong (e.g., shoplifting, child neglect). In our personal lives, we might choose to distance ourselves from such people, but in our professional lives, this might all be in a day's work. The range of behaviors that presents in our offices can seem overwhelming. We might wonder how we can even begin to help every person who walks through the door.

In this chapter, we discuss how you can gain confidence as a clinician. But, first, we offer a useful metaphor for the therapy process — going on a journey.

THERAPY AS A JOURNEY

Many people love to travel. Some people are "fly-by-the-seat of their pants" kinds of travelers, but more often than not people like to make a plan before leaving on a journey. After all, time and resources are limited when we travel, and we like to make the most of it!

Perhaps we begin planning a trip by choosing a general location. We can reach this decision based on who is going on the trip, what the weather is at the time of year we are traveling, consideration of cost, how much time we have, and so forth. Once a general location is selected, it can be helpful to print out a map of that area and trace a route from place to place that might end up on the itinerary.

It often makes sense to consider the beginning, middle, and end of a trip. On the first few days of a trip, we can get acquainted with the place we're visiting — maybe by walking around or taking a bus tour to get a sense of what would be interesting to see. The middle of the trip can be exciting — maybe a really long, strenuous hike in a national park, seeing and hearing an amazing concert, or having a meal at a special restaurant. And it's always nice to leave a day or two at the end of the trip to pack up your belongings and get things in order before heading back to "real" life.

The process of treatment planning in cognitive-behavioral therapy (CBT) is like making an itinerary for our trip. This itinerary leads us from the beginning of our trip to its end — and spells out all the points in between. As with a trip, therapy ideally begins with an acquaintance period. Therapist and client get to know each other, learn about the style of therapy and the presenting problem together, and discuss particular therapeutic strategies that may be employed both during and between sessions. The "exciting" part of the voyage involves all the tools of CBT — cognitive work, exposures, relaxation exercises, mindfulness techniques, and so forth — all carefully selected to get the client to an end point, some agreed-upon goal. Along the way, we might face challenges. When we travel, we might get a flat tire, someone might get ill, or a long-awaited attraction or destination might be closed for renovation or other unforeseen reason. In therapy, we might encounter clients who are resistant to change, clients who lead chaotic lives, or we — as therapists — might bring our own issues into the interpersonal relationship that make the process less than ideal. All these challenges must be effectively worked through so that the client can attain his or her goals in some reasonable time frame.

In the same way that it can be nice to enjoy a calm ending to a trip, therapy also should not finish abruptly. There is a way to conclude, to consider gains, and to ensure that these gains are maintained into the future. In other words, before hopping on a plane back to "real life," we want to ensure that our clients have packed their souvenirs (CBT strategies) in their luggage. Throughout this book, we discuss how to travel the path of CBT successfully with our clients.

It is essential to note that mapping out a plan in advance of a trip does not mean we cannot deviate from it. Maybe the hotel that looked great online turned out to be a dump. Perhaps a place where we planned to spend 2 days was so wonderful that we decided to spend 5 days there instead. Or, maybe we met a local fellow in a far-off place who took us on an adventure we could never have planned with our tour books back home. The case conceptualization is just like our trip...